乳腺癌前哨淋巴结活检的临床应用研究

目的探讨乳腺癌前哨淋巴结活检术（SLNB）在临床应用中的价值。方法应用亚甲蓝染色法对58例乳腺癌患者先行SLNB,随后行乳腺癌常规外科手术。结果58例患者中前哨淋巴结（SLN）检出率为93．1％,准确率为96．3％。假阴性率为5．71％,假阳性率为0;操作者的学习曲线、患者的年龄、原发肿瘤的部位影响SLN的检出率（P〈0．05）;肿瘤的大小、病理类型不影响SLN的检出率（P〉0．05）。结论乳腺癌SLNB能够准确地预测乳腺癌患者腋窝淋巴结（ALN）的转移情况。     

Reoperative sentinel lymph node biopsy in patients with locally recurrent breast cancer

BACKGROUND: Sentinel lymph node biopsy (SLNB) is considered a standard of care in the staging of breast cancer. The objective was to examine our experience with reoperative SLNB. METHODS: We identified 19 patients in our breast cancer database who had a SLNB in the reoperative setting. All 19 patients had undergone previous breast-conserving surgery with either an axillary lymph node dissection or an SLNB. The reoperative sentinel lymph node (SLN) was identified using blue dye, radioisotope, or both. RESULTS: The SLN was identified in 84% of the reoperative cases. Of these successful cases, both blue dye and radioisotope were used in five cases, and radioisotope alone was used in 11 cases. Radioisotope identified the SLN in the 100% of successful SLNB cases (P = .0003). There were 3 unsuccessful cases in which blue dye and radioisotope failed to identify the sentinel node. CONCLUSIONS: Reoperative SLNB after previous axillary surgery is technically feasible.     

腋窝淋巴结清扫术治疗前哨淋巴结活检阴性乳腺癌的系统评价

目的系统评价腋窝淋巴结清扫术治疗前哨淋巴结活检阴性乳腺癌的有效性和安全性。方法检索CNKI、PubMed、EMBASE、CBM从建库至2013年12月1日的文献资料,选择腋窝淋巴结清扫术和前哨淋巴结活检术治疗乳腺癌患者的试验,严格按照制订纳入和排除标准对纳入的研究进行筛选、资料提取、质量评价和结果分析。使用Revman 5.1软件,进行统计学分析(Meta-分析)。结果最终纳入10篇文献,患者共7731例。因纳入文献在研究类型、测量指标、随访时间以及统计学指标的差异较大,采用亚组分析,Meta分析同质研究,其余采用定性的描述性分析。本研究结果显示,在无病生存率、总体生存率、局部复发率、远处转移率方面,不同随访时间腋窝淋巴结清扫术与前哨淋巴结切除术间差异均无统计学意义。结论对于单发浸润性乳腺癌患者前哨淋巴结活检呈阴性时,可不必行腋窝淋巴结清扫术。目前尚需相关高质量随机对照试验和长期的随访进一步证实此系统评价的结论。     

Prediction of additional axillary metastasis of breast cancer following sentinel lymph node surgery

Sentinel lymphadenectomy is a sensitive and specific procedure that has reduced the need for complete axillary lymph node dissections in patients with negative sentinel lymph nodes (SLNs). However, numerous studies have shown that SLN may be the only positive lymph node in 40 to 70% of cases. This study was therefore undertaken to determine if the characteristics of primary breast tumor or its metastasis in the SLN could predict the presence of residual disease in the nonsentinel lymph nodes (NSLNs) and thus allow for further reduction in axillary lymph node surgery. The SLN procedure was performed on 329 patients at our institution, of which 131 had positive SLNs and underwent further axillary surgery. Fifty-four patients had additional disease in the NSLNs, while in the remaining 77 cases, no residual disease was detected. The clinical and pathologic features of these cases were reviewed and statistical analysis was performed. Multivariate analysis determined two significant independent variables for prediction of residual disease in the axilla: the size of the metastatic tumor in SLNs and the presence of its extranodal extension. The mean tumor size in SLNs without residual disease in NSLNs was 0.4 cm. It was 1.1 cm in patients with additional NSLN metastasis. The positive predictive value in both instances is about 80%. The risk of NSLN involvement in patients with SLN tumors of < or = 0.4 cm was 21%. The risk was the same (21%) for patients with micrometastatic disease (< or = 0.2 cm) in SLNs. In these cases the residual disease in the NSLNs was also small. SLNs with metastatic deposits larger than 1.0 cm were likely to contain additional metastases in the NSLNs in 81% of cases. This increased to 100% if the primary carcinoma was larger than 5 cm, if it was poorly differentiated, or if it showed HER-2/neu gene amplification. The presence of an extranodal extension of SLN metastasis was an independent predictor of residual axillary disease and was associated with NSLN metastasis in 76% of cases. Primary tumor characteristics did not correlate with the incidence of NSLN metastasis in our series.     

Early experience of sentinel lymph node biopsy in breast cancer with blue dye technique

Objective: Sentinel lymph node biopsy (SLNB) is a minimally invasive staging procedure for breast cancer. Results of the first 30 cases of SLNB performed at Kwong Wah Hospital, Hong Kong, were reviewed. Design: This feasibility study applied and assessed a new procedure in Chinese patients. The study was carried out at the Breast Centre, Kwong Wah Hospital, Hong Kong. Sentinel lymph node biopsy was performed with a blue dye technique alone. All patients had full axillary dissection after SLNB. Patients: Female patients with invasive carcinoma of breast and no clinical palpable axillary lymph node were included. Main outcome measures: Pathological results of both the SLN and the remaining axillary content were compared. Results and Conclusion: Sentinel lymph nodes were successfully biopsied in 83% of cases. Sensitivity was 75% and accuracy was 88%. With experience, sentinel lymph node biopsy is feasible in Chinese patients.     

应用亚甲蓝行乳腺癌前哨淋巴结活检276例分析

目的 探讨以亚甲蓝作为示踪剂行乳腺癌前哨淋巴结(SLN)活检的临床应用及影响因素.方法 分析了276例临床T1-T2 N0-M0乳腺癌患者前哨淋巴结活检(SLNB)结果,对SLN检出率及假阴性率影响因素进行了初步分析.结果 276例患者中,成功检出SLN者246例(检出率为89.1%).共检出SLN 423枚,每例1～4枚.前哨淋巴结对腋窝淋巴结转移情况预测的敏感性为77.3%(68/88),假阴性率为8.1%(20/246),假阳性率为0,准确率为91.9%(226/246).临床T2N0M0SLNB成功率高于临床T1N0M0乳腺癌患者(P=0.046);年龄<50岁者SLNB检出成功率高于年龄≥50岁病例(P=0.000),SLNB假阴性率年龄<50岁者显著低于高龄患者(P=0.037);外上象限和外下象限肿瘤SLNB检出成功率明显高于其他象限(P=0.000).内上象限肿瘤SLNB假阴性率高于外上及外下象限(P=0.018).临床TMN分期、EB、PR表达情况及病理类型对SLNB成功率及假阴性率无影响.结论 以亚甲蓝作为示踪剂行乳腺癌SLNB,患者年龄、临床TNM分期、肿瘤部位对SLN检出率有一定影响,患者年龄、肿瘤部位可影响SLNB假阴性率.     

Alternative sites of injection for sentinel lymph node biopsy in breast cancer

Background: Sentinel node biopsy is rapidly gaining popularity as a less invasive approach to nodal staging in breast cancer. The optimal route of injection of radiocolloids and dye is controversial. The purpose of the present paper was to review and assess the literature. Methods: A MEDLINE search for reports of studies involving different injection sites of colloid and/or dye was performed. Results: Although controversial, current evidence suggests that subareolar (SA) or intradermal/subdermal (ID/SD) injection will map the same axillary sentinel nodes (SN) as peritumoral (PT) injection in the vast majority of cases, is at least as successful, and is better logistically. Peritumoral, but not alternative routes, identify extra‐axillary sentinel nodes, which are important in a minority of patients. Conclusions: It is recommended that at least some of the radiocolloid be injected peritumorally to avoid missing those SN not located in the ipsilateral axilla. Injection of the dye and a portion of radiocolloid in an ID/SA location is reasonable to take advantage of the general ease and accuracy of ID/SA injections in identifying axillary SN.     

淋巴闪烁显像与乳腺癌前哨淋巴结活检

乳腺癌前哨淋巴结的精确定位是乳腺癌前哨淋巴结活检成功的先决条件之一,明确乳腺淋巴引流途径对乳腺癌前哨淋巴结的准确定位有重要指导意义。术前淋巴闪烁显像可提供个体化的淋巴引流特点,有助于确定前哨淋巴结的位置、数目及是否存在腋窝外前哨淋巴结。现对淋巴闪烁显像在乳腺癌前哨淋巴结活检中的应用现状和存在的问题进行综述。     

Acceptance of sentinel lymph node biopsy of the breast by all general surgeons in kentucky

Sentinel lymph node biopsy (SLNB) for breast cancer is now performed routinely in many U.S. medical centers. The acceptance of SLNB in the community and in rural medical centers, however, has not been accurately defined. The purpose of this study was to assess how surgeons in Kentucky, a predominantly rural state, have incorporated SLNB into practice. General surgeons in the state of Kentucky were identified by registration with the state medical association. All general surgeons (n=272) in the state were mailed the questionnaire, with 93% (n=252) responding. Overall, 172 defined themselves as rural surgeons. Among the rural surgeons, 87% perform breast cancer operations and 54% perform SLNB. In comparison, 74% of nonrural surgeons perform breast cancer operations and 80% perform SLNB. A majority of nonrural surgeons (73%) have performed SLNB for more than 2 years when compared to rural surgeons (73% versus 37%, respectively; p<0.0001). Planned backup axillary node dissection was stopped by both rural (26%) and community (39%) surgeons after 10 cases (14% rural, 19% nonrural) or 11--20 cases (12% rural, 20% nonrural). Surgeons reported using SLNB for the following diagnoses: invasive cancer (98%), ductal carcinoma in situ (DCIS) (43%), and lobular carcinoma in situ (LCIS) (11%). The majority of surgeons (87%) reported a greater than 90% SLN identification rate. SLNB has become widely accepted by surgeons in both rural and nonrural medical centers in Kentucky. However, there has been considerable variability in the number of training cases surgeons have performed prior to abandoning routine axillary dissection. This indicates a need for continuing educational efforts aimed at quality assurance.     

胃癌前哨淋巴结研究进展

前哨淋巴结是从原发肿瘤淋巴引流途中首先可能发生转移的部位。Cabana在阴茎癌中提出前哨淋巴结的概念后,前哨淋巴结活检技术不断在多种肿瘤中广泛应用。目前,该技术已成功用于黑色素瘤、乳腺癌等手术。但在胃癌中,由于胃淋巴引流复杂、存在跳跃转移以及假阴性率较高,前哨淋巴结活检技术应用于临床还为时过早,其可行性和适用性尚无定论。因此,前哨淋巴结活检技术应用于胃癌,还有许多问题需要回答。     

Women's choice between sentinel lymph node biopsy and axillary clearance

Purpose : To determine whether women would choose sentinel lymph node biopsy (SLNB) or axillary clearance (AC) for breast cancer treatment when they are given a single choice based on clear information about morbidity and mortality. Methods : The expected 5‐year survival rate of women with breast cancer after either SLNB or AC was calculated using a utility analysis of established literature. The difference in survival was one in 1000. This and other detailed information on SLNB and AC was presented in a questionnaire, which provided subjects with a scenario and a choice between SLNB and AC. After a pilot study of 40 subjects, the questionnaire was mailed to 400 women (who had no mammographic abnormality) attending Breast Screen and handed to 100 women (who were over 40 years of age and had breast symptoms but not cancer) attending the rooms of two surgical specialists. Results : One hundred and twenty one of the 243 respondents to the mailed questionnaires (49.8%) chose SLNB and 35% of the 100 consulting room subjects chose SLNB rather than AC. Conclusions : Women faced with the possibility of having breast cancer seem to be very conservative in their choice of treatment, many choosing the increased morbidity of AC rather than the very small (one in 1000) increased risk of death at 5 years from SLNB. This raises questions about proposals to offer SLNB as standard treatment and demands that women are fully informed about any increased risk of death when making their choice between SLNB and AC. Abbreviations: AC, axillary clearance; SLNB, sentinel lymph node biopsy.     

Contralateral axillary sentinel lymph node in breast cancer recurrence

The rare but significant reports of aberrant lymph node drainage outside of the ipsilateral axilla in patients with breast cancer necessitate a review of the staging and treatment strategies for these patients. Current staging modalities continue to describe this phenomenon as a stage IV cancer, which could have profound implications for clinical management. We report a case of a patient with recurrent right breast invasive ductal carcinoma whose preoperative lymphoscintigraphy revealed sentinel lymph node drainage to the contralateral axilla. This discovery subsequently altered surgical planning and her ultimate stage.     

Failure of sentinel lymph node mapping in breast cancer patients qualified for treatment sparing axillary lymph nodes—Clinical importance and management strategy—One‐center analysis

Sentinel lymph node biopsy (SLNB) is a standard in diagnostic and therapeutic management of patients with nonadvanced invasive breast cancer. The aim of this paper was to evaluate the clinical importance of the failure of sentinel lymph node (SLN) identification during SLNB performed to spare axillary lymph nodes. A total of 5396 patients with invasive breast cancer qualified for SLNB, treated in a period from Jan 2004 to June 2018. All cases of the failure of SLN identification and reasons underlying this situation were analyzed retrospectively. In 196 (3.6%) patients, SLN was not identified (group I), and this resulted in a simultaneous axillary lymph node dissection. 48.5% patients from this group were diagnosed with cancer metastases to lymph nodes (vs 23.6% patients with SLN removed—group II, P < .00001)—stage pN1 in 44.2% of the cases, stage pN2 in 22.1% of the cases, and pN3 in 33.7% (in group II—73.4%, 19.5% and 7.1%, respectively), with a presence of extracapsular infiltration in 68.4% patients (vs 41.7% in group II) and with a significantly higher percentage of micrometastatic nature in group II (17.0%, vs 3.2% in group I). The failure of intraoperative sentinel lymph node mapping indicates a significantly increased risk of breast cancer metastases to the axillary lymph system. At the same time, it can also indicate higher cancer stage and its increased aggressiveness. For this reason, in such situation performance of axillary lymph node dissection still appears to be the approach most advantageous for patients.     

Clinicopathologic analysis of sentinel lymph node mapping in early breast cancer

Axillary nodal status is the most significant prognosticator for predicting survival and guiding adjuvant therapy in breast cancer patients. Sentinel lymph node biopsy (SLNB) represents a minimally invasive procedure with low morbidity for staging axillary nodal status. In this article we review and report our experiences in patients with early breast cancer who underwent SLNB at the Revlon/UCLA Breast Center. Between September 1998 and May 2000, a total 83 SLNBs were performed in 81 patients with proven breast cancer and negative axillary examination who elected to have SLNB as the first step of nodal staging. Two patients had bilateral breast cancer. SLNB was localized by using both 99Tc sulfur colloid (83 cases) and isosulfan blue dye (75 cases). Data of these patients were prospectively collected and analyzed. The clinical and pathologic characteristics of women with positive and negative sentinel lymph nodes (SLNs) were compared to identify features predictive of SLN metastasis. Of the 83 cases, the SLN was successfully localized in 82 (98.8%). Sixty-three percent of patients had SLNs found in level I only, 18.3% in both level I and II, and 4.9% in level II alone. The vast majority (84.3%) of these cases had T1 breast cancer with an average size of 1.55 cm for the entire series. Twenty-three patients (28%) had positive SLNs, with an average of 1.5 positive SLNs per patient. Fifteen had metastases detected by hematoxylin and eosin staining and 8 had micrometastases detected by immunohistochemistry (IHC) using anticytokeratin antibodies. Ten of the former group agreed to and 2 of the latter group opted for full axillary lymph node dissection (ALND). An average of 17.5 lymph nodes were removed from each ALND procedure. Additional metastases or micrometastases were found in seven patients (in a total of 28 lymph nodes). Three patients with completely negative SLNs experienced additional axillary lymph node removal due to their election of free flap reconstruction. None had metastases detected in these lymph nodes. The absence of estrogen and progesterone receptors (ER/PR) by IHC (p = 0.036) and the presence of lymphatic/vascular invasion (LVI) (p = 0.002) predicted positive SLNs in patients with early breast cancer in a univariate analysis; in a multivariate analysis only LVI was predictive (p = 0.0125). Histologic type, nuclear grade, tumor differentiation, HER-2/neu and p53 status, S-phase fraction, and DNA ploidy did not predict SLN status. Immediate postoperative complications were uncommon and delayed complications completely absent. Because of the high detection rate, accurate staging, and minimal morbidity, SLNB should be offered as a choice to women with small breast cancers and clinically negative nodes. Because positive LVI and negative ER/PR status are highly predictive of pathologically positive SLNs in small breast cancers, women whose cancers meet these criteria should be advised preoperatively about their risk of having a positive SLN and may benefit from intraoperative assessment (frozen section and/or touch preparation) of their SLNs.     

前哨淋巴结活检在乳腺癌中的临床应用

目的 探讨术中前哨淋巴结（sentinel lymph node,SLN）定位和活检（SLNB）对预测乳腺癌腋窝淋巴结（axillary lymph node,ALN）转移的准确性.方法 对48例乳腺癌患者术前10min用亚甲蓝注射液4ml注射到肿瘤周围或活检腔的正常乳腺组织,进行SLN定位和活检,然后行乳腺癌改良根治术.结果 SLNB的检出成功率为95.8%,准确率为97.8%,假阴性率3.0%,假阳性率为0.结论 用亚甲蓝作SLN定位进行SLNB能准确预测乳腺癌ALN转移状态.     

Palpable breast carcinomas: a hypothesis for clinically relevant lymphatic drainage in sentinel lymph node biopsy

Previous studies have shown that independent of tumor size, palpable breast tumors have a higher incidence of lymph node metastasis compared with nonpalpable tumors. This study further examines this phenomenon using a large sentinel lymph node (SLN) database. Data from a prospective, institutional review board (IRB)-approved, multi-institutional study from the University of Louisville Breast Cancer Sentinel Lymph Node Study Group was used. From August 1997 through December 2001, 3192 patients with clinical T1 and T2 N0 breast cancer underwent SLN biopsy, most with a combined technique of radioactive colloid and blue dye, followed by level I/II axillary dissection. Patients with palpable tumors tended to be younger (mean age 58 years) compared with nonpalpable tumors (mean age 61 years). The incidence of positive axillary metastasis was significant between palpable and nonpalpable tumors (43% and 23%, respectively), independent of tumor size by logistic regression (p = 0.0001). The SLN identification rate was significantly different between palpable and nonpalpable tumors (95% versus 91%, respectively; p < 0.0001). A unifying theory to explain the phenomenon that palpable tumors, stage for stage, are associated with a higher rate of nodal metastasis is that palpable tumors are, on average, closer to the skin and the rich network of dermal lymphatics. We believe that the dermal lymphatics of the breast represent a clinically relevant metastatic pathway to the axilla.     

Intraoperative methylene blue sentinel lymph node mapping in colorectal cancer

Background: Isosulfan blue is not available for clinical use in Malaysia. This study describes the use of methylene blue as an alternative to isosulfan blue in colorectal sentinel node mapping. Methods: Methylene blue dye was injected around colonic and rectal tumours and the first blue‐stained nodes were suture tagged and harvested after standard colorectal resection. Standard histopathological examination was then carried out to detect nodal metastasis. All negative sentinel lymph nodes (SLN) were subjected to 10 further step sectioning and immunoperoxidase staining for cytokeratin 20 to detect tumour deposits. Results: Thirty‐one patients were enrolled from August 2005 to July 2006. Twenty‐five attempts at identifying the SLN were successful (80.7%). Of the 18 (58.1%) who had nodal metastases (stage III), 3 had negative SLN but positive other lymph nodes (false‐negative rate of 21.4%). In one (4%), the SLN was the exclusive site of metastasis. Conclusion: Methylene blue can be used as an alternative sentinel node marker for rectal cancer (above the peritoneal reflection) and colonic cancer.     

Axillary staging using positron emission tomography in breast cancer patients qualifying for sentinel lymph node biopsy

Axillary lymph node dissection (ALND) is the standard of care for nodal staging of patients with invasive breast cancer. Due to significant somatic and psychological side effects, replacement of ALND with less invasive techniques is desirable. The goal of this study was to evaluate the clinical usefulness of axillary lymph node (ALN) staging by means of positron emission tomography (PET) with 18F-fluorodeoxyglucose (FDG) in breast cancer patients qualifying for sentinel lymph node biopsy (SLNB). FDG-PET was performed within 1 week before surgery in 24 clinically node-negative breast cancer patients with tumors smaller than 3 cm. Sentinel lymph nodes (SLNs) were identified by preoperative lymphoscintigraphy following peritumoral technetium 99m-labeled colloid albumin injection, and by intraoperative gamma detector and blue dye localization. Following SLNB, a standard ALND was performed. Serial sectioning and immunohistochemistry of the SLN as well as standard histologic examination of the non-SLN was performed. FDG-PET detected all primary breast cancers. Staging of ALNs by PET was accurate in 15 of 24 patients (62.5%), whereas PET staging was false negative in 8 of 10 node-positive patients and false-positive in 1 patient. The sensitivity, specificity, positive predictive value, and negative predictive value of FDG-PET for nodal status was 20%, 93%, 67%, and 62%, respectively. The mean diameter of false-negative ALN metastases was 7.5 mm (range 1-15 mm). Lymph node staging using FDG-PET is not accurate enough in clinically node-negative patients with breast cancer qualifying for SLNB and should not be used for this purpose.